Quality Site Visit Report

Transcription

1 Quality Site Visit Report Part C HIV Early Intervention Services (EIS) Part D Grants for Coordinated HIV Services and Access to Research for Women, Infants, Children, and Youth (WICY) Part F - Dental Programs Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau Division of Community HIV/AIDS Programs Director: Polly E. Ross, M.D. Deputy Director: Lynn R. Wegman, M.P.A.

2 Purpose of Training Provide consultants with additional guidance for generating a quality site visit report Shorten the editing process once a draft report is submitted Reduce the amount of time that is necessary to finalize a report and have the report released to the grantee

3 Key Points When Writing the Site Visit Report Report should be a stand alone document Two audiences: HRSA Staff and Grantee Initial Site Visit Report submitted to the Project Officer by the Team Leader should be written: In concise and complete sentences Free of spelling and grammatical errors Free of duplicate information within the Overview With Findings and Recommendations numbered

4 Essential Resources HRSA/HAB/DCHAP Site Visit Assessment Tool (most recent version: February 6, 2015) Utilize the tool throughout the Site Visit to identify findings and craft language for reporting the findings within the online system. HRSA/HAB/DCHAP Site Visit Report Guidance Refer to the HRSA/HAB/DCHAP Site Visit Report Guidance throughout the process of completing the Site Visit Report template within the online system.

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6 Team Members Responsibilities Complete and submit the assigned section to the Team Lead within 5 business days of Exit Conference Check grammar, spelling, and sentence structure Verify that all information within the Overview adheres to what is requested by DCHAP within the Guidance Only use statements that are fact based Do not include proper names of staff, only position titles Never include confidential client information or client identifiers Avoid including sensitive information

7 Team Leader Responsibilities Submit a Site Visit Report that is limited to a total of 10 pages for a Part C and 15 pages for a Part C and D Program within 10 business days of the Exit Conference Prior to submitting the initial Site Visit Report to the Project Officer: Check all Team Members entries for spelling, grammar, and content Verify that all information within the Overview adheres to what is requested by Program within the Guidance and is not duplicative

8 Site Visit Report Template

9 Site Visit Report Template Sections General Information Grantee Information: Grantee Name; Grant Number; Grantee Address; Project Period; and Awardee Amount Type of Visit Date(s) of Visit Project Officer Contractor Staff List names of the consultants and their respective roles. DO NOT include personal contact information. Purpose of Visit

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12 Site Visit Report Template Sections

13 Site Visit Report Template (continued) Overview of Grantee Organization Introduction Administrative Overview Clinical Overview Fiscal Overview Requirements/Authorities: Finding(s) Recommendation(s)

14 Site Visit Report Overview Limit to 2 pages in length (including Introduction and all three sections: Administrative, Clinical, and Fiscal) Do not include Finding(s) and Recommendations Description of Technical Assistance or guidance provided by consultants can be included Remember to cite or reference all resource materials used to develop the overview section of the report Reference pages 4-6 of the Site Visit Report Guidance

15 Introduction Name of grantee Location of grantee s service site(s) Programs reviewed: RWHAP Part C and / or RWHAP Part D

16 Overview Format Broad Statements Concerning Grantee Activities Location Demographics Specific Healthcare Services or Challenges

17 Administrative Overview

18 Administrative Overview What is the length of time the organization has served in the target community? How long has the program served people living with HIV? Include the State s status as it relates to the Affordable Care Act Reference page 5 of the Site Visit Report Guidance

19 Administrative Overview Describe the program s service area, services provided, and how it effects the Affordable Care Act Include the most recent demographic data on clients receiving services Describe the organization s model of care and administrative structure Reference page 5 of the Site Visit Report Guidance

20 Models of Care AIDS Service Organizations / Community Based Organizations Federally Qualified Health Centers Models of Care Academic or University Medical Centers / Hospitals Departments of Health

21 Clinical Overview

22 Clinical Overview Describe model of clinical care and what services are available on site Do not have to include an extensive list and can summarize fully comprehensive and includes. Number of HIV patients receiving services funded by Ryan White HIV/AIDS Program Note if numbers are not reflective of approved work plan goals If patient numbers are higher it may be due to different funding streams or due to insurance status Reference pages 5-6 of the Site Visit Report Guidance

23 Clinical Overview (continued) Client demographics by race, age, gender, and mode of transmission Should not duplicate information included in the Administrative section Where do new patient referrals come from? Part D: Average number of HIV-positive pregnant women each year, as well as number of women, infants, children and youth. Reference pages 5-6 of the Site Visit Report Guidance

24 Clinical Overview (continued) Provide a brief overview of medical care provided including a description of whether the care is consistent with HHS Guidelines Describe whether there are clinical policies and procedures in place for HIV medical management Reference pages 5-6 of the Site Visit Report Guidance

25 Clinical Overview (continued) Provide a brief overview of the clinical chart review to include: Number of charts reviewed Overall assessment of documentation Results from the following two clinical quality measures Viral Load Suppression / Retention in HIV Medical Care Note: outcomes should be based on use of the HAB performance measure definitions for numerator and denominator Reference pages 5-6 of the Site Visit Report Guidance

26 Clinical Overview (continued) Provide a brief description of the clinical quality management (CQM) program to include: Status of a CQM plan CQM meeting structure and frequency Are consumers involved in program development, implementation, and evaluation activities? If so, how is this accomplished? Reference pages 5-6 of the Site Visit Report Guidance

27 Clinical (continued) Consumer Panel Overview Number of consumers in attendance and demographics Were they new or established patients What services have they received Briefly describe any concerns they expressed If positive feedback obtained, briefly describe that also Reference pages 5-6 of the Site Visit Report Guidance

28 Fiscal Overview

29 Fiscal Overview (continued) Describe the organization s accounting structure, funding sources, and revenue streams Include the payer mix, debt to asset ratio, and the process for tracking FTE s associated with the grant Describe the organization s process for collecting and tracking program income Provide the expenditure rate for the Part C and/or Part D Program Reference pages 6 of the Site Visit Report Guidance

30 Fiscal Overview (continued) Note the date of the most recent audit and any weaknesses or deficiencies Describe how the organization utilizes opportunities available through the Affordable Care Act (ACA) Reference pages 5-6 of the Site Visit Report Guidance

31 Requirements and Authorities

32 Requirements and Authorities If a Requirement is Met then place None next to Finding(s) and also next to Recommendation(s) Requirements that are Partially Met or Not Met require at least one finding and a corresponding recommendation Findings and Recommendations must be related to one of the 12 Requirements and documented in the appropriate Requirement section Findings should clearly state reason why grantee is not in compliance with the legislative or programmatic requirement and demonstrate a weakness Use complete sentences that are fact based Do not include Improvement Options or Best Practices Reference pages 6-7 of the Site Visit Report Guidance

33 Requirements and Authorities (continued) Recommendation(s) should correlate with Finding(s) Each Finding(s) and Recommendation should be numbered the same starting from #1 under each Requirement: Findings: Finding 1: XXX Finding 2: XXX Recommendations: Recommendation 1: (based on Finding 1) Recommendation 2: (based on Finding 2)

34 Recommendations Clearly state the recommendation and include recommended steps/actions needed for the grantee to address the specific Finding(s) and achieve compliance with the Requirement(s) Describe the role and/or technical assistance HRSA can provide or help to facilitate for the grantee

35 Additional Tips Ryan White Program should be written out as: Ryan White HIV/AIDS Program (RWHAP) Be sure to spell out acronyms with initial use and then the acronym can be used for the remainder of the Site Visit Report Avoid use of tables only narrative format Only documents vetted by HAB/DCHAP can be shared with grantees

36 Combined Part C & D Site Visits The Site Visit Report format will vary if the Part C & Part D programs function as two separate programs Discuss Site Visit Report format with Project Officer in advance of the site visit

37 Additional Tips Subheaders must be used to identify RWHAP Part C and RWHAP Part D content

38 Combined Part C & D Site Visits Combined subheaders must be used to identify RWHAP Part C/RWHAP Part D content when applicable

39 Combined Part C & D Site Visits Part C & Part D programs functioning separately require two Consumer Panels

40 Overall assessment of a Requirement, as well as individual Finding(s) and Recommendation(s) must be identified as to whether it applies to RWHAP Part C, RWHAP Part D or both

41 Formulating Report Requirement #1: RWHAP Part C Met Finding(s): None RWHAP Part C Recommendation(s): None Requirement #1 RWHAP Part D Partially Met Finding 1: XXX Finding 2: XXX RWHAP Part D Recommendation 1: (Based on Finding 1) Recommendation 2: (Based on Finding 2)

42 Formulating Report RWHAP Part C

43 Formulating Report RWHAP Part D

44 Formulating Report Combined RWHAP Part C & Part D

45 It takes the entire Site Visit Team working together to produce a Quality Site Visit Report!

46 Questions

47 Thank you for your participation in today s webinar!